QUALITY AND PATIENT

SAFETY AUDIT

AUDIT REPORT EXECUTIVE SUMMARY

Audit Title:

Audit of compliance with Standard 3 of HSE Standards and

Recommended Practices for Healthcare Records Management
(HCRs) V3.0

Audit Number:

QPSA002/2014

Audit Period:

March July 2014

Audit Team Members:

1) Ms. Petrina Duff, Quality and Patient Safety Audit, HSE (Lead)
2) Mr. Alfie Bradley, Quality and Patient Safety Audit, HSE
3) Ms. Catherine Timoney, Quality and Patient Safety Audit, HSE

Audit Sponsor:

Ms. Edwina Dunne, Director Quality and Patient Safety Audit, HSE

Source of Evidence:

Type

Date

Request for Evidence

Evidence returned between 10 and 14

April 2014

Site Visits:
Cavan General Hospital
University Maternity Hospital Limerick
St. Vincents University Hospital
Our Ladys Childrens Hospital Crumlin

06 May 2014
14 May 2014
23 May 2014
28 May 2014

1. AUDIT BACKGROUND/RATIONALE
In 2011 the Health Service Executive (HSE) published Standards and Recommended Practices for
Healthcare Records (HCRs) Management V3.0 2011 (hereafter referrred to as the HSE HCRs Standards
V3.0), which includes the National Maternity Healthcare Record (NMHCR). The aim of the HCRs
management programme is to provide a framework for consistent and coherent HCRs in the HSE, which
in turn will support high quality services and patient safety.
This audit is a repeat of the audit QPSA005/2013 Audit of compliance with Standard 3 HSE Standards
and Recommended Practices for Healthcare Record Management, which was undertaken between April
and July 2013 in four acute hospitals. This current audit (QPSA002/2014) involved four different acute
hospital sites. The purpose of the audit was to determine the level of compliance with selected criteria
from Standard 3 of the HSE HCRs Standards V3.0 in relation to the content of HCRs and that the
Standard is fit for purpose.
2. AUDIT OBJECTIVES
The objectives of this audit are to determine:
1) The level of compliance with specific criteria selected from Standard 3 of the HSE HCRs Standards
V3.0 in four acute hospitals.
2) The communication, training and induction strategies adopted and implemented by the four acute
hospitals following publication of the HSE HCRs Standards V3.0.

3. SIGNIFICANT FINDINGS
Objective 1:
Evidence from the review of HCRs demonstrated that all four hospitals have attained a high level of
compliance in relation to most of the criteria selected from Standard 3 of the HSE HCRs Standards V3.0.
In all four sites attention is required in relation to the use of unapproved abbreviations, which when found,
were not written in full as required by the Standard. A consistent approach to the documenting of allergies
and alerts in the designated section of the HCR is also required. Deficits were identified in the area of
patient name and identification number on each page, documenting time, the use of the 24 hour clock and
the name of the primary clinician being clearly identifiable in the HCR at all times.
Objective 2:
Two sites had clear HCRs governance structures in place, one site had deficits in relation to their
commitment to attend regular HCRs committee meetings and the other site had no active local HCRs
governance group and had disengaged from the regional HCRs governance group. HCRs PPPGs were
evident to varying degrees in all sites, however three of the sites did not reference the HSE HCRs
Standards V3.0 in any of their documents.
One site demonstrated a proactive HCRs training and induction strategy. The other three sites
demonstrated shortfalls in relation to HCRs training and induction.
All four hospitals provided evidence of HCRs audit activities demonstrating an ongoing commitment to
providing assurance on HCRs management within the hospital environment.
During site visits, the audit team sought the opinion of the hospitals on the structure and content of the
HSE HCRs Standards V3.0 document and its launch process in 2011. The main report contains the detail
of this opinion. It is suggested that their responses may add value to future versions of the HSE HCRs
Standards document.
4. RECOMMENDATIONS
1. QPSD to ensure that in new versions of the HSE HCRs Standards document, criterion 3.3.15 is
reworded to exclude the term during the working week.
2. The HSE Code of Practice for Healthcare Records Management Abbreviations (2010) booklet requires
immediate updating by QPSD to include clinical terms that are now in common use.
3. QPSD to ensure that in new versions of the HSE HCRs Standards document, criterion 3.3.25 is
reworded to state that abbreviations used in HCRs must be on the list of approved abbreviations.
4. QPSD to ensure that in new versions of the HSE HCRs Standards document, it is clearly stated that
allergies and alerts are to be recorded in the designated section on the inside cover of the HCR.
5. QPSD to reinforce in new versions of the HSE HCRs Standards document that all hospitals are to
implement training and induction strategies in respect of HSE HCRs Standards documentation.
5. CONCLUSION
The review of the HCRs demonstrated that all four sites maintained a high level of compliance with most
of the selected criteria from Standard 3 of the HSE HCRs Standard V3.0. A lower level of compliance was
noted in the need for a consistent approach to documenting allergies and alerts in the designated section
of the HCR, the inappropriate use of unapproved abbreviations and in the requirement for the name of the
primary clinician to be clearly identifiable in the HCR at all times.
There was reasonable evidence provided by three of the four hospitals to demonstrate that formalised
HCRs governance arrangements are in place. There was a lack of HCRs training, education and
induction in three of the four hospitals. HCRs internal audit was of a high standard in all four hospitals.
Recommendations made in this report identify actions that must be implemented at national level in order
to improve compliance with Standard 3 of the HSE HCRs Standards. Findings from this audit, in
particular, feedback from the four hospitals and the innovative practices observed will support the
development of future versions of the Standards.